LUNG CANCER PATIENT SUPPORT ECHO SESSION 4 …
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LUNG CANCER PATIENT SUPPORT ECHO SESSION 4 TOBACCO CESSATION: SUPPORTING PATIENTS ACROSS THE CANCER CONTINUUM AUGUST, 2018 9:00 AM ET
Transcript of LUNG CANCER PATIENT SUPPORT ECHO SESSION 4 …
LUNG CANCER PATIENT SUPPORT ECHO SESSION 4
TOBACCO CESSATION:
SUPPORTING PATIENTS ACROSS THE CANCER CONTINUUM
AUGUST, 2018
9:00 AM ET
TODAY’S AGENDA
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*Sessions will be recorded.*Please mute phones when not speaking. Mute cell phones and try to reduce extraneous noise. *Remember to e-mail Octavia Vogel by if you are requesting CME/CEU credit.
Time Presentation Presenter (s)
9:00-9:10 Welcome, roll call, housekeeping Thomas Asfeldt, RN
9:10-9:45 Didactic Presentation: ECHO
Session 4
Tom Houston, MD
Angela Criswell, MA
Jamie Ostroff, Ph.D.
9:45-10:00 Q & A/Discussion Facilitated by Thomas Asfeldt
10:00-10:15 Program/Case Presentation Hope Gibson, BSN, RN
Scotland Cancer Center
10:15-10:25 Q & A/Discussion Facilitated by Thomas Asfeldt
10:25-10:30 Conclusion/Next session Thomas Asfeldt/Octavia Vogel
DISCLOSURE
UNM CME policy, in compliance with the ACCME Standards of
Commercial Support, requires that anyone who is in a position
to control the content of an activity disclose all relevant financial
relationships they have had within the last 12 months with a
commercial interest related to the content of this activity.
The following planners and faculty disclose that they have no
financial relationships with any commercial interest.
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FACILITATOR & PRESENTERS
Lead Facilitator: Thomas Asfeldt, RNSanford Health Systems
Presenters: Tom Houston, MD (Primary Care Physician)AAFP Rep to Nat’l Lung Cancer Roundtable
Angela Criswell, MALung Cancer Alliance
Jamie Ostroff, Ph.D. (Psychologist)Memorial Sloan Kettering Cancer Center
Case Presentation: Hope Gibson, RN, BSN (Oncology Navigator)Scotland Cancer Center
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TOBACCO CESSATION: CHALLENGES
IN LUNG CANCER SCREENING
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Tom Houston, MD
Clinical Professor, Family Medicine
The Ohio State University
LEARNING OBJECTIVES
❑ Following the presentation, participants should be able to:
Discuss tobacco dependence as a chronic relapsing condition
Identify key psychological and physiological features of nicotine addiction
Summarize the major recommendations of the US Public Health Service Clinical
Practice Guidelines for treating tobacco use and dependence
Describe the value of multiple sources of intervention in implementing
cessation support for patients across the cancer continuum
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SMOKING IN PERSPECTIVE
Kills more than 488,000 Americans each year
Causes cancer, heart disease, stroke, pulmonary disease, and adverse pregnancy outcomes
Adds >$170 billion in direct health costs each year
Indirect costs, productivity losses $150 billion/year
Half of all smokers will die from a tobacco related disease unless they quit by middle age
OPPORTUNITY FOR CLINICIANS
70% of smokers see a physician/other clinician each
year.
70% of smokers want to quit.
Physician’s advice to quit is an important motivator.
Patients are more satisfied with their health care if
their provider offers smoking cessation interventions -
even if they’re not yet ready to quit.
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Tobacco dependence is a chronic condition
All tobacco users should be offered evidence based treatment
Behavioral interventions—even if brief—are effective
Strong dose response:
Length of visits
Number of visits
Number of providers intervening
Pharmacologic treatment is effective and at least one medication should be prescribed as part of the treatment plan.
The combination of behavioral intervention and pharmacotherapy is optimal.
Treatment of tobacco dependence is cost-effective
Healthcare systems must systematize treatment of tobacco dependence
CANCERS CAUSED BY SMOKING
Lung
Larynx
Esophagus
Stomach
Pancreas
Kidney/Bladder
Cervix
Oral/pharyngeal
Acute myeloid leukemia
Colon/rectal
TOBACCO SMOKE AND CARCINOGENESIS
4000-7000 chemicals and between 60 and 300 carcinogens
Induces carcinogenesis through
DNA adduct formation
Free radical formation
Oxidative stress
Inhibition of apoptosis
Radiation effects (Polonium 210)
Freiman A. J Cutan Med Surg. 2004;8(6):415-423; Hecht. Nat Rev Cancer. 2003;3(10):733-743; Stavrides.
Free Radic Biol Med. 2006;41(7):1017-1030.
RELATIVE RISK OF LUNG CANCER BY
NUMBER OF CIGARETTES SMOKED PER DAY
1-9 10-19 20 21-39 40+0
2
4
6
8
10
12
14
16
18
20
Rela
tive R
isk
Number of Cigarettes per Day CPS1 Data14
LUNG CANCER MORTALITY RISK
Current smoker lung cancer mortality risk
11.82 (95% CI, 10.73-13.03)
Former smoker lung cancer mortality risk
4.15 (95% CI, 3.75-4.49)
National Longitudinal Mortality Study
JAMA Int Med 2018; 178(4):469-476
LUNG CANCER MORTALITY RATES FOR SMOKERS, NEVER
SMOKERS AND SMOKERS WHO QUIT AT AGE 50
0
100
200
300
400
500
600
700
800
40-44 45-49 50-54 55-59 60-64 65-69 70-74
Death
Rate
per
100,0
00
Age Group CPS I Data
Residual risk
Risk avoidedby cessationCessation at
age 50
Risk of acontinuing smoker
UNIQUE QUALITIES OF NICOTINE
ADDICTION THROUGH SMOKING
Cigarette is a highly engineered drug-delivery system
Inhaling produces a rapid distribution of nicotine to the brain
Drug levels peak within 10 seconds in the brain
Acute effects dissipate within minutes, causing the smoker to continue frequent dosing throughout the day
Average smoker takes 200-300 boluses to the brain
per day
Nature 1989;393:76
BIOLOGY OF ADDICTION
▪ Addictive drugs stimulate release of
dopamine (brain neurotransmitter)
▪ Dopamine produces feelings of pleasure
▪ Pleasure reinforces repeat administration
▪ Tolerance develops
▪ Abrupt discontinuation leads to symptoms
of withdrawal
NICOTINE WITHDRAWAL SYMPTOMS
Constant craving of
cigarettes
Insomnia
Irritability
Anxiety
Frustration
Anger
Depression
Difficulty concentrating
Restlessness
Decreased heart rate
Increased appetite
Withdrawal peaks within 24-48 hours and
diminishes over 1 month.
smoking heroin alcohol
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ASSESS
Have you recently quit?
Any challenges?
ASSIST
Provide appropriate tobacco
dependence treatment
ASSIST
Intervene to increase
motivation to quit
ASSIST
Provide relapse
prevention
ASSIST
Encourage continued
abstinence
Do you currently use tobacco?
YES
NO
YES NONO
YES
ADVISE to quit
ASK
Have you ever used tobacco?
YES NO
ARRANGE FOLLOW-UP
ASSESS
Are you willing to quit now?
The 5 As: Treating Tobacco as a
Chronic Disease
ASK
THE 5 A’S
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ASK/ACT
ASK/ADVISE/REFER
❑Ask every patient about tobacco use
❑Act to help them quit
On-site counseling/Advice
Pharmacotherapy
Follow-up
❑ Refer to local cessation resources
Quitlines
Patient education materials
Self-help guides or Websites
OPPORTUNITIES ABOUND FOR
INTERVENTION
Primary care office
Routine care visits
Lung cancer screening discussion
At the referral site
After the scan
At follow up with PCP/referral source
At the next screening cycle
SMOKING CESSATION AND LUNG CANCER
SCREENING: A LOVE STORYGROWING FROM A MARRIAGE OF CONVENIENCE INTO LIFE PARTNERS
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WE CAN’T GO ON TOGETHER WITH
SUSPICIOUS MINDS
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• Will screening replace cessation as public health priority?
• Will smokers substitute screening for cessation?
Public Health/
Cessation
CommunityLung Cancer
Screening
Community
DO YOU REALLY WANT TO HURT ME? DO YOU
REALLY WANT TO MAKE ME CRY?
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• Screening is already complex. How do we add cessation to all of the other things we’re responsible for?
• How can we “make” people quit?
• If we don’t get people to quit, have we failed?
Screening Program Staff:
Carter-Harris L., Gould MK., “Multilevel Barriers to the Successful Implementation of Lung Cancer Screening: Why Does it Have to Be So Hard?” Ann AM Thorac Soc. 2017 Aug; 14(8): 1261-1265
DON’T SPEAK, I KNOW WHAT YOU’RE
THINKING. DON’T TELL ME ‘CAUSE IT HURTS.
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Carter-Harris L. “Lung cancer screening: what do long-term smokers know and believe” Health Expectations. 2015. [background focus group discussion notes provided by author]; Courier-Journal, 4/4/17
“You feel stigmatized for having a lung scan, because you’re stigmatized for smoking….”
“…They look at you like you’re a low life, uneducated, and just an ignorant person. You smokers….”
Online comment
to news story on
tobacco control
efforts in KY.
Patient frame of reference: anticipated stigma and judgement
SO DARLIN’, DARLIN’, STAND BY ME
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Moyer, V. and USPSTF Annals of Internal Medicine. 2014; CMS NCD CAG-00439N, 2/5/2015.
“All persons enrolled in a screening program should receive smoking cessation interventions….The USPSTF encourages incorporating such interventions into the screening program.
• SDM must include counseling on maintaining abstinence if former smoker, importance of cessation if current smoker, information on cessation interventions if appropriate.
• Radiology imaging facility criteria: must “make available smoking cessation interventions for current smokers.”
I WANT TO KNOW WHAT LOVE IS.
I WANT YOU TO SHOW ME.
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0102030405060708090
100
Baseline
Repeat Scan
Ostroff, et al., Nicotine & Tobacco Research, 2015, 1-9
Cessation Practice Patterns, Screening Centers of Excellence, 2014 Survey
THIS IS HOW WE DO IT…
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29
72
81
142
153
157
0 20 40 60 80 100 120 140 160 180
Other
Online Resources
Counseling outside Facility
Printed Resources
Counseling within Facility
Quitline
Smoking Cessation Resources Used
# of Facilities Using Resource
222 Health Systems Reporting2017 Screening Centers of Excellence Application Update
BUT HERE’S MY NUMBER, SO CALL ME MAYBE
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41.4%58.9%
YesNo
2017 Screening Centers of Excellence Application Update 222 Health Systems Reporting
Does your program conduct follow-up with smokers referred to cessation services?
• Follow-up by treatment counselor
• Phone calls from screening program at 3 & 6 months
• In person follow-up at next visit
• Fax or EHR update from Quitline
IS THIS SHALLOW LOVE?
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A patient’s smoking history, as viewed by a “basic, out-of-the-box” EHR:
• Smoking status• Type of tobacco used• # of cigs/packs per
day/week• If quit, number of
years• Might also capture #
of previous quit attempts
Source: Schindler-Ruwish et al., TBM 2017;7:148-156
YOU COMPLETE ME
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Source: Schindler-Ruwish et al., TBM 2017;7:148-156
EHRs can more fully document and support cessation interventions, but modification requires energy and resources.
Ask: tobacco use status & historyAdvise: language advising quit, documentation of advice givenAssess: prompt to ask about & document willingness to quit Assist: brief counseling language; referral to TTS, Quitline; medication prescribing, dosage decision support; patient education materials; treatment order setArrange: support for patient follow-up; electronic “pass back” of patient notes from TTS or Quitline.
HELP ME GET MY FEET BACK ON THE GROUND
WON’T YOU PLEASE, PLEASE HELP ME?
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https://lungcanceralliance.org/for-professionals/
http://www.lung.org/assets/documents/tobacco/billing-guide-for-tobacco.pdf
TOBACCO CESSATION: CHALLENGES
IN LUNG CANCER CARE
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Jamie Ostroff, PhD
Memorial Sloan Kettering Cancer Center
HEALTH CONSEQUENCES OF SMOKING
Source: Surgeon General’s Report, 2014
HEALTH CONSEQUENCES OF SMOKING FOR
CANCER PATIENTS/SURVIVORS
Adverse health outcomes of cigarette smoking in
cancer patients and survivors
Cigarette smoking increases all-cause
mortality
Cigarette smoking increases cancer-specific
mortality
Cigarette smoking increases risk for second
primary cancers.
Cigarette smoking increases risk for disease
recurrence .
Adverse health outcomes provide strong
justification for the integration of evidence-based
tobacco treatment in cancer care settings
Surgeon General’s Report, 2014
WHY BOTHER?
Improves survival
Decreases risk of disease recurrence
Decreases risk of second primary cancers
Decreases risk of treatment (surgery, radiation, chemotherapy) side effects and complications
Improves treatment response and effectiveness
Decreases risk of other tobacco-related comorbid conditions (CVD, COPD)
Improves quality of life (better pain control, reduced distress/stigma)
Park et al, Cancer, 2012
Smoking Rates by Cancer Type
PATTERNS AND PREVALENCE OF SMOKING FOLLOWING
DIAGNOSIS OF LUNG, HEAD/NECK CANCERS
Source: Burris, Studts, DeRosa & Ostroff, 2015, CEBP
36.7
24.6
31.928.6
81.7
63.7
52.1
38.1
0
10
20
30
40
50
60
70
80
90
100
Before Treatment (n=30/5 studies)
During Treatment (n=21/7 studies)
After Treatment (n=26/7 studies)
Mixed (n=33/15 studies)
Pre
vale
nce (
Mean
)
Treatment Phase
Full Sample Current Smokers at Cancer Diagnosis
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NCCN CLINICAL RECOMMENDATIONS
• Combining pharmacologic therapy and behavior therapy is the most effective approach and leads to the
best results for smoking cessation.
The two most effective pharmacotherapy agents are combination nicotine replacement therapy
(NRT) and varenicline.
High-intensity behavior therapy with multiple counseling sessions is most effective, but at least a
minimum of brief counseling is highly recommended. Quitlines may be used as an adjunct, especially in
lower-resource settings.
• Smoking status should be documented in the patient health record. Patient health records should be
updated at regular intervals to indicate changes in smoking status, quit attempts made, and interventions
utilized.
• Smoking relapse and brief slips are common and can be managed. Providers should discuss this and
provide guidance and support to encourage continued smoking cessation attempts. Smoking slips are not
necessarily an indication to try an alternative method. It may take more than one quit attempt with the
same therapy to achieve long-term cessation.
• Smoking cessation should be offered as an integral part of oncology treatment and continued
throughout the entire oncology care continuum, including surgery and end-of-life care. An emphasis
should be put on patient preferences and values when considering the best approach to fostering smoking
cessation during end-of-life care.
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DESIGN
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Tobacco Treatment
Patient enters cancer center
Patient identified as smoker
Not current smoker
Patient scheduled for appointment
Smokers recruited
Randomized
4 biweekly proactive counseling sessions + medication
4 weekly counseling sessions + medication
6-month survey
3 monthly proactive booster counseling sessions
3-month survey
Patient’s current smoking confirmed
Refusal/Ineligible
Cancer treatment plan determined
Standard Treatment
4 weekly counseling sessions + medication advice
Ca
nce
r T
rea
tme
nt
Cancer Treatment
Intensive Treatment
RESULTS
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Park, Ostroff et al 2018, Annual ASCO Meeting, Chicago
MODELS OF TOBACCO TREATMENT IN CANCER CARE
Ask about current tobacco use
Advise all current smokers to quit
Oncology care team selects model of tobacco treatment delivery
Provide cessation counseling and prescribe
cessation medications
Referral to Integrated Tobacco Treatment Program
Referral to community-based cessation support services (quitline; Smokefree.gov;
groups)
ASK --- ADVISE --- REFER
Your patients are more likely to become smoke-free if you advise them to quit smoking and encourage them to work with our tobacco treatment counselors.
Empathic discussion may improve patient engagement and influence adherence to the treatment plan with greater appreciation of how important quitting is for their treatment and overall health outcomes.
Refer patients to the Tobacco Treatment
Program
Take Away
PROVIDE RATIONALE FOR
ASKING, ADVISING AND REFERRING:
TALKING POINTS
Quitting smoking can help reduce surgical complications and
shorten recovery time
Quitting smoking lowers the risk of your cancer coming
back or getting a different tobacco-related cancer
People with cancer who stop smoking respond better to
chemotherapy and radiation, live longer, and have fewer sides
effects from their treatments
Safe and effective tobacco treatment exists
We have staff with specific expertise in helping cancer
patients quit and stay quit
ASCO TOBACCO TREATMENT TOOLKITS
Next Training Workshop will be heldOctober 19 & 20, 2018New York City
For more information,
visit: www.mskcc.org/TobaccoCare
Supported by NCI Award R25CA217693
CASE STUDY
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Hope Gibson RN, BSN, Oncology Navigator
Scotland Cancer Treatment Center
1. POPULATION OF SCOTLAND COUNTY IS 35K AND DESIGNATED AS A RURAL COUNTY
2. RANKED 2ND HIGHEST IN STATE FOR UNEMPLOYMENT AND IS RANKED 99TH OUT OF 100 FOR
HEALTH OUTCOMES.
3. IN 2016 THERE WERE 423 DEATHS AND 108 WERE CANCER RELATED DEATHS WITH CARDIO
RANKED 2ND
4. AND LUNG CANCER IS THE #1 CAUSE OF DEATHS
Our hospital campus went tobacco free in 2006
We have a Certified Tobacco Treatment Specialist (CTTS)
Classes are offered as people call to schedule
RESULTS OVER LAST 12 MONTHS:
19 referrals received
11 registered for class (58%)
10 attended class (91%)
5 completed (50%)
Reasons for not attending/completing tobacco cessation class :1. Transportation2. Someone else in home is smoker – difficult for successful quitting3. “Not ready to Quit”
LDCT SCREENINGS
86 LDCT PERFORMED IN 2016
170 LDCT PERFORMED IN 2017
113 RECEIVED LDCT SO FAR IN 7/2018 (PROJECTED TO EXCEED 2017)
2017: 91% BASELINE SCREENINGS / 9% ANNUAL SCREENINGS
2018: 83% BASELINE SCREENINGS / 17% ANNUAL SCREENINGS
2018 ADDITIONAL STATS
68% WERE CURRENT SMOKERS
AVERAGE PACK YEAR WAS 40
MEDIAN AGE WAS 65
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5 72 2
Lung Rad 1 Lung Rad 2 Lung Rad 3 Lung Rad 4A Lung Rad 4X incomplete
0
10
20
30
40
50
60
70
113 Patients with LDCT Results in 2018
CASE STUDIES
COMMUNITY OUTREACH
• In 2017, 3 industries/community events were offered LDCT screening tool.
• 265 Encounters with 155 people completed the survey tool
• 11 met criteria and was referred back to PCP
• Only 1 out of the 11 had LDCT performed which resulted in a LungRad 3 (short term FU)
CESSATION CASE STUDIES
1. Head & Neck Cancer that MD said if you don’t quit smoking I can’t treat
you because…..
Patient attended tobacco cessation class and quit. Subsequently received
radiation therapy.
2. 34 year old female snuff dipper – surgical patient -accepted and scheduled
for class but did not show up
3. 30 year old male smoker with hematology issues and mother present –
accepted our handouts and information but very reluctant to engage in
conversation about quitting.
Suggestions/recommendations/ideas?
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JOIN US NEXT MONTH FOR LUNG CANCER PATIENT
SUPPORT ECHO SESSION 5
TREATMENT PLANNING: OVERCOMING LACK OF
CONCORDANCE WITH STAGING AND MANAGEMENT
GUIDELINES
THURSDAY, SEPTEMBER 27, 2018
9:00 AM ET
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Presenters:Gerard Silvestri, MD (Pulmonologist)
Professor of Medicine Medical University of South Carolina
Patricia Rivera, MD (Pulmonologist)Clinical Research, Thoracic Oncology Program
School of Medicine, UNC-Chapel HillFacilitator/Co-Presenter:
John Ruckdeschel, MD (Oncologist)
Director, UMMC Cancer Institute
Case Presentation:Volunteers needed
